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HomeMy WebLinkAboutBP21-039PERMIT#_�/- �f� C�3� DATE: � J �� p(p•. ) o1e� f SECTION /��, �a� B��cK / InT �'7 �� TYPE OF WORK ,� JOB LOCATION � OWNER_���`�,�L CONTRACTOR y aI, EST. �CO #, �� n 0 mra es l �y�- %9�9 � �.55- � DA TCO # FEE DATE INSPECTION RECORD DATE FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING 0 FZGH PLUMBING GAS SPRINKLER ELECTRIC LOW -VOLT ALARM As BUILT FINAL 1 NSP e ....� ,_ � �' :. r�S-k3UILTIFINAL SURVEY REQUIRED PRIOR TO FINAL INSPECTION i ��� 12I i Z12�-�-- VILLAGROF R�TE BROOK WESTCHESTER COUNTY, NEW YORK No: 22-197 Certificate of ®ccupautp Ehis is to certify that Pec+o y m ova l eE�> R ( 4o. O QJ o y t e sS of, P'41C y-oo y—1 NV , having duly filed an application on DR-0-PCri b e r /J+-20-sZQ requesting a Certificate of Occupancy for the premises known as, c-23 Li nco In Avt�� u , Rye Brook,NY, located in a Zoning District and shown on the most current Tax Map as Section: 5, (05 Block: / Lot: and having fully complied with the requirements of the Building Code and the Zoning Ordinance under Building Permit No. �/-V 5 ,issued ) 20 C2 1 ,such authority and permission is hereby granted to the property owner to lawfully occupy or use said premises orbuilding or part thereof listed under the following New York State Classifications, Use: )2,,.//Q� c)Ae - Fa fYI/ �/ Construction: V13 for the following purposes: r a it l- 5 ex par"" Yee r fp( yz6 Subject to all the privileges, requirements, limitations, and conditions prescribed by law, and subject also to the following: This certificate does not in any way relieve the owners or any person or persons in possession or control of the premises, building,or any part thereof from obtaining such other permits or licenses as may be prescribed by law for the uses or purposes for which the building or premises is designed or intended. Furthermore, it does not relieve such owners or persons from complying with any lawful order issued with the object of maintaining the premises or building in a safe and lawful condition. No changes or rearrangement in the structural parts of the building or in the exit facilities shall be made, and no enlargement, whether by extending on any side or by increasing in heig t shq1I ,xer shall the building be moved from one location to another until a permit to accomplish such change has b e . ding Inspector. Building Inspector,Village of Rye Brook: �Ii� Date: DEC 2 1 2022 D EC BUILD For office use only: DBUILDING DEPARTMENT PEItM� DEC 12 2022 VILLAGE OF RYE BROOK ISSUED: 39 8 KING STRExT,RYE BROOK,NEW YORK 10573 DATE: (914)939-0668 FEE: 16 PAID 0/ VILLAGE OF RYE BROOK BUILDING DEPARTMENT www•rvgbre0korg APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCE, AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION i►►►ttt\\\itt►tt►tl►\\\tt\t/t►tt►t►■\t4itt■tit/tttttt\ttttt►t■t►►t \\\►tt\tt►■►tt►t►\\\\it►►t►t►cttitt�ttt►\ttt►ttttttt\\\\\t►►t■ Address: A3 Li )J CO L 0 1 c, B /v I J Occupancy/Use: )-'Fa rn i I�.1 Parcel ID#: 5 . 6 5— '- L Zone: �C - io Owner: T 6t le5 Address: �1 k/cow ALIE 6PDX t 7� P.E./R.A.or Contractor: ki 0 e VA Address: l Peq r(�� �R'` C* r 11x73 Person in responsible charge: Address: Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance with law: STATJE'OF NEW YORK,COUNTY OF WESTCHESTER as: / lJc f/ N�Gn d being duly sworn,deposes and says that he/she resides at (Print Name ofApplicant) (No.and Street) in C- �yG� ,in the County of in the State of�,that (Cityrrown/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equip/m/eennt,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ /2,—O U for the construction or alteration of LI/4 Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate of Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been erected/completed in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per§250-10.A.of the Code of the Village of Rye Brook. Sworn to before me this a<_ Sworn to before me this day of (2(f"- ,20 2 Z day of , 20 Si!7thre of Property Owner Signature of Applicant /7/e" Tv/� /'>U,2/� Print Name of Property Owner Print Name of Applicant Notary — JOHN M St107Z0 Notary Public �y PuBuo,sn�1E of Hewrdre pegwadon No.01SW070019 pualKled in Westchester C)U* MY comhwca Exphes March 11,2025 8/12/2021 �yE BRC�uk 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR ❑ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAX (914) 939-5801 www ryebrook.ors - - - - - - - - - - - - - - - - - -- - - INSPECTIONREPORT - - - - - - - - - - - - - - - - - - - - ADDRESS:— 12 / 1�ol0 DATE: PERMIT# i ISSUED. ECT: I BLOCK: LOT: LOCATION: OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/REINSPECTION ❑ SITE INSPECTION �, �, REQUIRED ❑ FOOTING \ ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ NATURAL GAS ❑ L.P.GAS ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION 0 FINAL ❑ OTHER Mike Izzo From: Mike Izzo Sent: Tuesday, March 1, 2022 9:57 AM To: Katherine Morales; Mommy Cc: Steven Fews; 'Tara Gerardi'; Laura Petersen Subject: RE: Request permit extension for 23 Lincoln Avenue, permit BP 21-039 Dear Ms. Morales, Thank you for the email. I am pleased to inform you that a six (6) month extension to your open permit #BP 21-039 has been approved, and that the new expiration date is, September 9, 2022. Please arrange for all work to be completed and successfully inspected, and for all paperwork & fees to be remitted to the Village such to facilitate the issuance of the Certificate of Occupancy/Certificate of Compliance closing out the permit on or before that date. Thank you. 44aell(7, Aza Building& Fire Inspector Village of Rye Brook, NY (914) 939-0668 From: Katherine Morales<kmorales@opentable.com> Sent:Tuesday, March 1,2022 9:05 AM To: Mommy<ritamorales221@gmail.com>; Mike Izzo<Mlzzo@ryebrook.org> Subject: Request extension for permit BP 21-039 Hi Michael Hope you are having a great Tuesday morning. I am reaching out on behalf of my mother who lives at 23 Lincoln ave. It was brought to my attention that the permit we applied for expired today March 1 and the work has not been completed. I realize should have reached out earlier. They had a few delays-weather, contractor getting Covid and than our family going through quarantines and Covid themselves it's been a quite a bit these past few months. Hoping to extend another 6 months. Please let me know if anything else I need to do to help the process. Thank you again Katherine Morales Katherine Morales i I E c0 w w a � o ►"ri W .cl 661 _ ° RE , a a � a WM : O � � o CIA C6 QQ • 1 G , Q c o X a CS Ono w to at d rWn s � W d Building Permit Check List&Zoning Analysis Address: Z i t r.3 C o c,1- SBL: Zone: '1- L O Use: 21 a Const.Type: 3 Other. Submittal Date: I L� '� Revisions Submittal Dates: Applicant: Nature of Work: � O 4- Reviews:ZBA: NOV - 4 2020 PB: BOT: Other. OK ( ( ) FEES:Filing. 7S= �� BP: C/O: Legalization: ( ) (�APP: Dated: ✓ Notarized SBE `Truss I.D. Cross Connection: H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENVIRO:Long. Short: Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site[rotection: S/W Mgmt.: Tree Plan. Other. SURVEY:Dated: 3 I Z I o Current: Archival: -- Sealed. Unacceptable: ( ( ) PLANS:Date Stamped: Sealed Copies: Electronic: Other. ( ( ) License: ✓ Workers Comp: ✓ Liability Comp.Waiver. Other. ( ) ( ) CODE 753#: Dated: N/A: ( ) ( ) HIGH-VOLTAGE ELECTRICAL:Plans: Permit: N/A Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL:Plans: Permit: N/A: Other. ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Permit: H.W.I.C.:_Battery._Other. ( ) ( ) PLUMBING Plans: Permit: Nat.Gas: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit: N/A: Other. ( ) ( ) H.V.A.C.: Plans: Permit: N/A Other. ( ) ( ) FUEL TANK:Plans: Permit: Fuel Type: Other. O O 2020 NY State ECCC: N/A: Other. (� ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other. ( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER: Other. ( ) ( ) Other. (�ARB mtg.date: i k approval• 01 l notes: ( )ZBA mtg.date: approval• notes: ( )PB mtg.date: approval• notes: REOUIRED EXISTING PROPOSED NOTES APFKOVLU NOV 2 3 2020 Area l 0 k l E �� (� — Q�L Date: Cirde: T— Fro=g Front: Front: Sides: RCar. Main Cov: Accs.Cov: Ft H Sb: S .H Sb: Tot. FtFt.ImD: Paz Hei ht/Stories: notes: D [ � LD �I[ _�_ ; BUILDING DEPARTMENT VILLAGE OF RYE BROOK ENOV - 2020 938 KING STREET RYE BROOK,NY 10573 (914)939-0668 FAx(914)939-5801 VILLAGE OF RYE BROOK www.rygbrook,org I BUILDING DEPARTMENT ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS This form must be completed and signed by the applicant of record and a copy shall be submitted to the Building Department prior to attending the ARB meeting. Applicants failing to submit a copy of this check list will be removed from the ARB agenda. Job Address: a 3 Uvtcdth hj cL Date of Submission: r1 OJ Lt aA Q-0 Parcel ID#: 135-. laS—I— `l I Zone: SS4$OS Proposed Improvement(Describe in detail): APPLICANT CHECK LIST: MUST BE COMPLETED BY THE APPLICANT Rc ao;r,a bwCK Pn i-io r4�a llcn 3 S�y P'f The following items must be submitted to the Building hluf- S*NW— De7mcompleted ent by the applicant-no exceptions. l. Application 2. ( Two(2)sets of sealed plans. (one full size(maximum Property Owner: PL,- be- 3 wvo<-a le-$ allowable plan size=36"x 42")and one 1 I"x17) Address: a 3 t',n c alh Pry C. Ric. j6mg ` 3. (\ Two(2)copies of the property survey. 4. (N,�Two(2)copies of the proposed site plan. Phone# 91 q $H 4 +9 a O� 5. (v�One electronic/disc copy of the complete Applicant appearing before the Board: application materials.6. ( )Filing Fee. NGc ha r S vv,6r-C I -S 7. ( )Any supporting documentation. 8. ( )HOA approval letter. (ifapplicable) Address:_ 9-3 I i nc pl►-, Av-C. Quz_ 6Yoct I� �`( 9. Photographs. Phone# q tY %Lf �LA � aq 10.( )Samples of finishes/color chart. la sample board or Architect/Engineer: model may be presented the night of the meeting) Phone# By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit Instructions&Procedures, and that their application is complete in all respects. The Board of Review reserves the right to refuse to hear any application not meeting the requirements contained herein. Sworn to before me this r///R I? Sworn to before me this 3 day of ry/A jZ pl/, 20 Z Q day of A119 I/ 120.00 Signat./ifkrAperty Owner Sign P pliffeant hH e c?O)Q -M oR A /-ES C c-r c2k f t ok A 1 FS' Print Name of Property Owner Print Name of Applicant Notary Public Notary Public III 3/21/19 VILLAGE OF RYE BROOK BUILDING DEPARTMENT 938 KING STREET, RYE BROOK, NY 10573 (T) 939-0668 (F) 939-5801 ARCHITECTURAL REVIEW BOARD Wednesday, November 18, 2020 Due to public health and safety concerns from COVID-19, the Architectural Review Board meeting on November 18, 2020 will be closed to members of the public. The public can still watch the live meeting online through Zoom through the app or through the following https://us02web.zoom.us/j/82249823211 If any interested members of the public would like to provide comments during the meeting, comments can be emailed to stevefews@ryebrook.org or called in during the meeting at +1 (929) 205-6099, meeting ID: 822 4982 3211 NAME & LOCATION TYPE OF APPLICATION MOTION SECOND APPROVED REJECTED APPL.# 16 Maywood Ave Replace Rear Yard Wood Consent 5091 (Robles) Fence w/ 6Ft Agenda 19 Maywood Ave Driveway Widen, Retaining Consent 5100 (Ocasio) and Wall Fence Agenda 16 Hillandale Road New 4'-0" High Post and Consent 5101 (Harmon) Rail Fence w/Wire Mesh Agenda 717 Westchester Ave New 4' High Open Picket, Consent 5102 (Shehata) Front Yard and 6'High Agenda White Vinyl Fence Rear Yard. 6 Legendary Circle Post& Rail Fence In Rear Consent 5103 (Goodman) Yard Agenda 476 N. Ridge Street Roof Top Solar Array Consent 5104 (Sidelev) Agenda 47 Mohegan lane 6Ft High White Privacy Consent 5105 (Shapira) Fence, @ Rear Lot Line Agenda 23 Lincoln Ave Re- Do & expand Rear Patio Consent 5106 (Morales) Agend��- 165 Betsy Brown Amendment to Prior Consent 5063 ML NM MR, -SE JM- SF A AC ! MI . KC Road(Valad) Approval, (Front Door Agenda Change) 35 Bonwit Road Replace Driveway R.R. Tie Consent 5107 (Sedrish) Walls w/Mesa Block Agenda 72 Valley Terrace Re-Appearance 2nd Story 5097 (72 Valley Terrace Addition & Alterations LLC) 11 Winding Wood Legalize Rear Elevated 5108 Road(Kotlin) Deck 6 Winding Wood Window Changes & Sky 5109 Road Lights/To Accommodate (Escobar/Otero) Kitchen Renovation I 7 Beechwood Blvd Application to Amend Prior 5110 (Schoeman) Approval 12 Birch Lane Roof Over Rear Patio 5111 (Shaw) Extension, Outdoor Kitchen & Remove Gazebo 116 Country Ridge Rear Addition, Inground 5112 Drive (Jacobs) Swimming Pool, Deck, & Outdoor Kitchen 3 Charles Lane Rear Deck, Roof Covered 5113 (Abraham) Extended Patio, Fire Pit, BBQ & Sitting Wall 21 Woodland Drive 2nd F1 Addition, & 1 Story 5114 (Morrisey) Addition S. C. Rye Brook Construct Playground Area 5115 Partners S.E. Corner i ML NM MR SE JM SF AC MI KC Tara Gerardi From: Tara Gerardi Sent: Monday, November 30, 2020 3:32 PM To: h.jaime.morales@gmail.com Subject: Building Permit 23 Lincoln Avenue Attachments: bp-1[1].pdf Importance: High The building permit application has been approved by the Building Inspector, before I can issue the building permit the following items must be submitted to our office, 1. General contractor's contact name. 2. Copy of general contractor's valid Westchester County Home Improvement License. 3. General contractor's valid liability insurance (the Village Of Rye Brook must be the certificate holder) 4. General contractor's valid workers compensation on a NY State Board form (C 105-2 or U26.3) 5. Building permit fee $180.00 (due once permit is issued and ready for pick-up) If you are acting as general contractor you must submit the following, 1. Declarations page of your homeowners insurance policy. 2. Attached BP-1 waiver form. 7'ara .A. Gerardt Secretary - Planning Board, Zoning Board of.Appeals & .Architectural Review Board TiClage of Rye Brook 938 acing Street Rye Brook, New York 10573 Office (914) 939-0668 Fax (914) 939-5801 Laura Petersen From: Laura Petersen Sent: Tuesday, December 15, 2020 11:39 AM To: MORALESK87@GMAIL.COM Subject: Building Permit Application - 23 Lincoln Avenue The building permit application has been approved by the Building Inspector, before I can issue the building permit the following items must be submitted to our office, . General contractor's contact name & phone number. _ 2. Copy of general contractor's valid Westchester County Home Improvement License. General contractor's valid liability insurance (the Village Of Rye Brook must be the certificate holder) 4. General contractor's valid workers compensation on a NY State Board form (C 105-2 or U26.3) 5. Building permit fee $180.00 (due once permit is issued and ready for pick-up) This information can be emailed to me. Thank you and have a great day! V CenA e 1 Laura Petersen Office Assistant ell C11-Village of Rye Brook 938 King Street Rye Brook, New York 10573 Phone(914)939-0668 1 Fax(914) 939-5801 1 Ioetersen0!yebrook.or�7c �9 �> _ o:o: .o:oo.o.o:o:o•o'o,o-oec.o:o...o-o u,o'o.¢o:o:vo:o.ao:o'o', - --------- 'o a 11- i •p O O � O _ 9 r C / CN :� •y`o \ II v � i o • Q 'b' r• r. t%o CN a :o 'x E ^y i q 1 "rX o Y ;O •1'O O p GLOp d O O C � O X. F G - LLI LLJ LIJ F o O O p G p O p G S G � O O 0 pmonoSx AIL Sri e CN co to � ::c 6 o fF�^• ' O 4 f O 4 Gl` O O J 4to4 O Q O O 1 Nd u •a � -'O'O'A .O.:O:O. .0.b:O:s:Oie[ .O:a0.b:o:1:M.O:O:OA. ,gpA(4 gob:O.0A:0:0:0.40.0:e.O,O:O;o:O:o o;O'O.O. .O.O;o:e;O;e:s:0'O'O.0 o:0:0 'O'e C j� v �11•f�` � yHl��• ' l^ •t J� �� F '✓. lei i l4. �J �1 l• I 'I• i .I - K, X�`I '`- _ k n vr"�� � v.• f •••. r.� �.>° {•v. �,rw•r'y -�M[/ �••..�f[r Vy [. �`' s•. .. VINCVIL-01 BE EL1 ACORO DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 311/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements). PRODUCER CONTACT Ellen Goldman(egoldman@butwin.com) Nathan Butwin Company Inc. AICO,No,E:t):(516)466-4200 nlc,No):(516)466-4213 60 Cutter Mill Rd.Ste.414 Great Neck,NY 11021 E-MAIL .info@butwin.com INSURERS AFFORDING COVERAGE NAIC N INSURER A:Utica First Insurance Co. 15326 INSURED INSURER B: Vicente Villanueva dba Villanueva Landscaping INSURER C: 119 Pearl Street INSURER D: Port Chester,NY 10573 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRA X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 300,000 CLAIMS-MADE FX—]OCCUR ART512403002 1/15/2021 1/1512022 DAMAGE TO RENTED 50,000 MEDEXP(Any oneperson) 1,000 PERSONAL&ADV INJURY 300,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 600,000 X POLICY D PRO LOC PRODUCTS-COMP/OP AGG $ 600,000 OTHER $ AUTOMOBILE LIABILITY (Ea accidentl COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS SSWN p BODILY INJURY Per accident $ AUTOS ONLY A�OS ONLY Perr acGden DAMAGE $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE DED I I RETENTION$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Rye Brook THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 Y ACCORDANCE WITH THE POLICY PROVISIONS. 938 King Street Rye Brook,NY 10573 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NYSIF New York State Insurance Fund WESTCHESTER ONE,44 SOUTH BROADWAY. 10TH FLOOR,WHITE PLAINS. NY 10601-4411 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A A 208925855 h LYNNE MAISONET AGENCY 238 WESTCHESTER AVE Eli PORT CHESTER NY 10573 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER VICENTE VILLANUEVA VILLAGE OF RYE BROOK 119 PEARL STREET 938 KING STREET PORT CHESTER NY 10573 RYE BROOK NY 10573 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE W2482 083-9 165512 08/17/2020 TO 08/17/2021 2/26/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2482 083-9, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY, IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 213062669 U-26.3 v 0 0 c cc' C11 m I < G1p--1Z0v_0fVrmm-I-4Z-Iw; cti no z>m- >mDO=v=m �0 rM;U;u 0: � --M.rv�-n0lviDmc�Xrz*�I� � cu O mmIT10 O CxKr-uymm z cam U)Xu) r-vmrX�m-qU) . 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Boa Z o � C) � � -n _ 00 '•a "n oo t° 0 r+ _ c Z oO cD MMZy �3 � O � O m N O n ��N< O r 7r 41 m CO) < -e IE (/) 5* 0 C 0 LSO--< • (/1 j-s co o Z 0 p 0 Z 33.3' `� m Z M r— C: 3: 1 01-4 0 IT71 %0 ree" .-. r p C) =0 OD O 0 fl I M • o 0 yy a ?N 0 CA (A 4bo oo y rn ZCD y 0 0 Asphalt Driveway y __ z-�+ *I I m " O C3 rn cnr CA 36.0' o�"z 0 w-��z 0 Gravel OD C 3 Areas - rn rU 0.2N Wire Fence o Wood Fence Along Line CDm S 80°24'10" W 150.00' ov < 0 <O �� 0 m Z m M O C� , G7 � N cn o m N M;D A y G islop �v CID D mO z 0 LA w -r 0